Infectious Disease Answer

 

Diagnosis: Acute rheumatic fever

Criteria: Jones criteria

 

Acute rheumatic fever (ARF) is a sequella of symptoms that typically occur 2-4 weeks after an untreated bout of group A Streptoccocal (GAS) pharyngitis.  Symptoms include arthritis, carditis, erythema marginatum, CNS symptoms, and subcutaneous nodules.

 

Jones criteria is constellation of symptoms of ARF and are subdivided into major and minor manifestations.

 

Major

Carditis

Arthritis

CNS involvement

Subcutaneous nodules

Erythema marginatum

Minor

Arthralgia

Fever

Elevated acute phase reactants

Prolonged PR interval

 

The diagnosis of ARF is made using the Jones criteria and is positive if the patient has evidence of a preceding GAS infection and:

  • Two major manifestations

or

  • One major and two minor manifestations

Infectious Disease Question

 

You are participating in a medical mission in South America and are seeing a 11yo boy who is brought in by his mother.  He has been complaining of joint pain and fever for the past 2 weeks.  She tells you that it seems to “move” from joint to joint over this time and nothing seems to help.  She does report that he has seemed to be sick for 4-6 weeks with various “cold” symptoms, but they didn’t seem too severe.  On examination, he has temperature of 101.2oF and the below rash.

erythema-marginatum-pictures-2

 

What should be your concern and what criteria can help make the diagnosis?

Update to Pneumonia Podcast

 

It figures.

 

As with any educational or academic en devour, as soon as you finish a paper/poster/presentation, a new publication comes out that would have been awesome to include.  I finished and published the Pneumonia podcast on July 12th and on July 14th, the IDSA/ATS released their updated guidelines on managing healthcare-associated (HAP) and ventilator-associated (VAP) pneumonia.  Luckily, they didn’t change anything earth-shattering, just tightened them up a bit.  Antibiotic regimens are below and they recommend 7-days total of therapy.

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2016 IDSA/ATS Guidelines

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2016 IDSA/ATS Guidelines


References

#16 – Pneumonia



 

Classifications of Pneumonia

  • Community-Acquired (CAP)
  • Healthcare-Associated (HAP)
    • Any IV therapy, wound care, or chemotherapy within 20 days
    • Resident of nursing home or other long term care facility
    • Hospitalization for ≥ 2 days within 90 days
    • Visit to outpatient clinic or hemodialysis within 30 days
  • Ventilator-Associated (VAP)
    • Currently or previously intubated during current hospitalization

Epidemiology

  • 6 cases per 1000 persons per year (~ 5 million cases per year)
  • Top 10 in mortality in US (~60,000 deaths/year)
  • 12% 30-day mortality in patients requiring admission
  • 28% all-cause mortality within one year

 

Pathogenesis

4 phases of development

  • Edema
    • Proteinaceous exudate in the alveoli
    • Bacteria accumulation
  • Red hepatization
    • Erythrocyte extravasation
  • Grey hepatization
    • Neutrophil extravasation with bacterial clearance
  • Resolution
    • Macrophage proliferation with inflammatory response

 

Picture1

Murthy SV. Pathology of Pneumonia. SlideShare.

Risk Factors

  • Age
  • Winter months
  • Increased risk of aspiration (AMS, CVA, intoxication, seizures)
  • Smoking
  • Underlying pulmonary disease (Asthma, COPD, cancer)
  • Immunosupression
  • Viral URI
  • Decreased host defenses (impaired ciliary clearance)
  • Acid-reducing medications
  • Malnutrition
  • Inhalation exposures
2

Up To Date. 2016.

 

Pathogens

  • Viral (most common)
    • Rhinovirus (most common)
    • Influenza
    • Adenovirus
    • Respiratory Syncytial Virus (RSV)
  • Bacterial
    • S. pneumoniae (most common CAP)
    • H. influenza
    • M. pneumoniae (most common atypical)
    • K. pneumoniae (tends to be more severe)
    • Legionella
    • ESKAPE bugs (>80% of VAP)
      • Enterococcus
      • Staphylococcus
      • Klebsiella
      • Acinetobacter
      • Pseudomonas
      • Enterobacter
  • Fungal (immunocompromised)
    • Histoplasmosis
    • Cryptococcus
    • Coccidioides
    • Blastomycosis
    • Aspergillus

Signs and Symptoms

  • Productive cough
  • Fever
  • Chills and/or rigors
  • Dyspnea
  • Pleuritic chest pain
  • Nausea/vomiting
  • Altered mental status

 

Physical Exam Findings

  • Vital signs
    • Febrile (elderly may not mount a response)
    • Tachycardic
    • Tachypnic
  • Pulmonary
    • Rales and/or rhonchi
    • Signs of consolidation
      • Decreased breath sounds
      • Dullness to percussion
      • Increased tactile fremitus
      • Egophany
      • Whispered pectoriliquoy

 

Radiographic Evaluation

  • Bacterial
    • Unilateral, lobar, air bronchograms

3

  • Viral
    • Diffuse or perihilar, bilateral

4

Laboratory Evaluation

  • CBC with differential
  • Blood cultures
  • Sputum culture and gram stain
    • Good sample = PMNs with < 10 squamous cells per LPF
  • Urine antigen (pneumococcal and Legionella)
  • Multiplex PCR
5

Up To Date. 2016.

Should They Stay or Should They Go Now????

  • Pneumonia Severity Index (PSI)
    • Step 1
      • If none of the following, then Class I and outpatient treatment
        • Age > 50 years
        • Neoplastic disease
        • Heart failure
        • Cerebrovascular disease
        • Renal disease
        • Liver disease
        • Altered mental status
        • HR ≥ 125/min
        • RR ≥ 30/min
        • SBP ≤ 90 mmHg
        • Temperature ≤ 35oC or ≥ 40oC
    • Step II
Screen Shot 2016-07-12 at 7.45.22 AM

Step II of PSI/PORT Score for Risk Stratification

  • CURB-65 Score
    • 5 variables
      • Confusion
      • Urea (BUN ≥ 20 mg/dL)
      • Respiratory rate ≥ 30/min
      • Blood pressure (SBP < 90 mmHg or DBP < 60 mmHg)
      • Age ≥ 65 years
    • Interpretation
      • Score 0-1 = Outpatient management
      • Score 2-3 = Inpatient management
      • Score 4-5 = ICU management
  • SMART-COP Score
    • Used to predict need for respiratory or vasopressor support

6

 

Treatment

  • Care should be taken to think about patients with risk factors for drug-resistant S. pneumoniae:
    • Age > 65 years
    • Beta-lactam, macrolide, or fluouroquinolone in the past 3-6 months
    • Alcoholism
    • Medical comorbidities
    • Immunosuppression
    • Exposure to child in daycare
  • Community-Acquired
7

Treatment for Community-Acquired Pneumonia. IDSA/ATS 2007 Guidelines.

  • Healthcare-Associated
8

Treatment of Healthcare-Associated Pneumonia. IDSA/ATS 2007 Guidelines.


Cottage Physician

CottageMD

Cottage Physician. 1893.


References

  1. Mandell LA, Wunderink RG. Pneumonia. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill; 2015. http://accessmedicine.mhmedical.com/content.aspx?bookid=1130&Sectionid=79733578. Accessed July 11, 2016.
  2. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. American journal of respiratory and critical care medicine. 171(4):388-416. 2005. [pubmed]
  3. File TM, Marrie TJ. Burden of community-acquired pneumonia in North American adults. Postgraduate medicine. 122(2):130-41. 2010. [pubmed]
  4. Murthy SV. Pathology of Pneumonia.    http://www.slideshare.net/vmshashi/pathology-of-pneumonia.  Accessed on July 11,  2016.
  5. Almirall J, Bolíbar I, Balanzó X, González CA. Risk factors for community-acquired pneumonia in adults: a population-based case-control study. The European respiratory journal. 13(2):349-55. 1999. [pubmed]
  6. Mandell LA, Wunderink RG, Anzueto A. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 44 Suppl 2:S27-72. 2007. [pubmed]
  7. Musher DM, Thorner AR. Community-acquired pneumonia. The New England journal of medicine. 371(17):1619-28. 2014. [pubmed]
  8. Jain S, Self WH, Wunderink RG. Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults. The New England journal of medicine. 373(5):415-27. 2015. [pubmed]
  9. Metlay JP, Kapoor WN, Fine MJ. Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA. 278(17):1440-5. 1997. [pubmed]
  10. Fine MJ, Auble TE, Yealy DM. A prediction rule to identify low-risk patients with community-acquired pneumonia. The New England journal of medicine. 336(4):243-50. 1997. [pubmed]
  11. Lim WS, van der Eerden MM, Laing R. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 58(5):377-82. 2003. [pubmed]
  12. Charles PG, Wolfe R, Whitby M. SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 47(3):375-84. 2008. [pubmed]
  13. Pugh R, Grant C, Cooke RP, Dempsey G. Short-course versus prolonged-course antibiotic therapy for hospital-acquired pneumonia in critically ill adults. The Cochrane database of systematic reviews. 2015. [pubmed]

#7 – Zika Virus

What is it?

The Zika virus is a flavivirus that is related to yellow fever, dengue fever, West Nile, and Japanese encephalitis.  It was first discovered in 1947 in a rhesus monkey and is called “Zika” because it originated in the Zika forest in Uganda.  It is transmitted by the Aedes species of mosquitoes (which also carries dengue, chikungunya, and yellow fever).

Kaddumukasa MA. J of Medical Entomology. 2014;51(1):104-113

Kaddumukasa MA. J of Medical Entomology. 2014;51(1):104-113

Whats with all the noise?

In May 2015, the Pan American Health Organization (PAHO) issued an alert regarding the first confirmed Zika virus infection in Brazil.  Since then, there have documented cases of Zika virus infections in 20 countries in North and South America.  Due to the threat and concern of transmission, the Center for Disease Control (CDC) issued a travel alert (Level 2-Practice Enhanced Precautions) for anyone traveling to these regions (see current list here).

Screen Shot 2016-02-01 at 11.48.58 AM

CDC Travel Alert Notice

Map2

CDC Map of Reported Active Transmission

Map3

McNeil DG. SHort Answers to Hard Questions About Zika. New York Times. 2016

Signs and Symptoms

Only 1 in 5 people who become infected by the Zika virus develop symptoms, which are usually a mild viral prodromal syndrome (fever, rash, arthralgias, myalgias, conjunctivitis).  Serious manifestations can include Guillaine-Barre syndrome and congenital microcephaly.  Brazil has seen a 20-fold increase in number of cases of microcephaly from 2010 to 2014.  Since October 2015, there have been 4,180 suspected cases (average of ~150/yr) of microcephaly in Brazil, but only 700 mothers were tested for the virus with only 270 positive results.  The first case of microcephaly associated by the Zika virus on US soil was in Hawaii on January 15th, 2016 to a mother who lived in Brazil.

Map4

McNeil DG. Short Answers to Hard Questions About Zika. New York Times. 2016.

Because of the surge of microcephaly cases in an endemic region of Zika, the CDC is recommending that women who are pregnant, or are trying to become pregnant, should post-pone any travel to these regions.

Map5

McNeil DG. Short Answers to Hard Questions About Zika. New York Times. 2016.

Testing

Signs and symptoms of the acute Zika infection are very non-specific and the list of differential diagnoses is broad.  If a patient has any suspicious symptoms within one week of travel to any of the at-risk regions, testing should occur as the Zika virus has become a nationally notifiable condition by the CDC.  Testing includes reverse transcriptase-polymerase chain reaction (RT-PCR), virus-specific IgM and neutralizing antibodies and are only performed at the CDC Arbovirus Diagnostic Laboratory.  Clinicians should contact local health departments to facilitate obtaining the correct testing sample and expediting transfer to the lab.

Treatment and Prevention

There is no specific treatment for the Zika virus.  Treatment plans should be directed towards symptom relief and includes rest, oral rehydration, and acetaminophen for fever and pain relief.  Aspirin and other NSAIDs should be avoided until dengue fever can be ruled out to decrease the risk of hemorrhage.

If travel must occur to endemic regions, patients should be advised to follow strict mosquito precautions to try to limit the exposure from the Aedes vector.  N,N-Diethyl-meta-toluamide (DEET), Picaridin, oil of lemon eucalyptus, and IR3535 are all recommended by the CDC and are safe in pregnancy.  There is no vaccine to the Zika virus yet, but preliminary works seem to be promising and early reports are pointing to the end of 2016 as a reasonable estimate for human trials to start.

Repellents

CDC Recommendations for Repellents

Bottom Line

For a PA practicing in the United States, this just adds to the list of traveler’s disease that you have to be hypervigilant about in patients with general complaints and recent travel to endemic regions.  By no means do we need to start screening every patient with viral symptoms for Zika.  But…if your patient has traveled to these regions, is pregnant, or may come into contact with patients who are pregnant, you should contact your local health department and screen them appropriately now that it is a nationally reportable disease.  You should also take appropriate quarantine precautions if your clinic/department also has pregnant patients to limit disease contact to the most at risk patients.  To date, there are no direct transmission cases of the virus (only the Aedes vector), but viruses can shift fast and it is better to be safer than sorry.

References

  1. Lucey DR, Gostin LO. The Emerging Zika Pandemic: Enhancing Preparedness. Published online January 27, 2016. doi:10.1001/jama.2016.0904.
  2. Kaddumukasa MA, Mutebi JP, Lutwama JJ, Masembe C, Akol AM. Mosquitoes of Zika Forest, Uganda: Species Composition and Relative Abundance.  J of Medical Entomology.  2014;51(1):104-113.
  3. (2016, January 29). In Wikipedia, The Free Encyclopedia. Retrieved 17:33, January 31, 2016, from https://en.wikipedia.org/w/index.php?title=Aedes&oldid=702307969
  4. Zika virus. Centers for Disease Control and Prevention Available at: http://www.cdc.gov/zika/.  Accessed February 1, 2016.
  5. Areas with Zika. Centers for Disease Control and Prevention Available at: http://www.cdc.gov/zika/geo/index.html. Accessed February 1, 2016.
  6. Brazil: 270 of 4,180 suspected microcephaly cases confirmed. The Big Story. Available at: http://bigstory.ap.org/article/25bba65de82b437080bedd4f9e229280/brazil-270-4120-suspected-microcephaly-cases-confirmed. Accessed February 1, 2016.
  7. Mcneil DG, Louis CS, St N. Short Answers to Hard Questions About Zika Virus. The New York Times Available at: http://www.nytimes.com/interactive/2016/health/what-is-zika-virus.html. Accessed February 1, 2016.
  8. Diagnostic Testing. Centers for Disease Control and Prevention Available at: http://www.cdc.gov/zika/hc-providers/diagnostic.html. Accessed February 1, 2016.
  9. Could We Have a Zika Vaccine Soon? NBC News. Available at: http://www.nbcnews.com/storyline/zika-virus-outbreak/could-we-have-zika-vaccine-soon-n507186. Accessed February 1, 2016.
  10. The Brazilian Doctors Who Sounded the Alarm on Zika and Microcephaly. WSJ. Available at: http://www.wsj.com/articles/the-brazilian-doctors-who-sounded-alarm-on-zika-and-microcephaly-1454109620?mod=e2tw. Accessed February 1, 2016.